Follow up of the agreed actions from the 2015/16 Health & Safety audit report

City of York Council 2017/18

Memorandum

For: Assistant Director, Customer Services & Digital, Head of Health & Safety Status: Final Date Issued: 25/1/2018

Where information resulting from investigation and/or audit work is made public or is provided to a third party by the client or by Veritau then this must be done on the understanding that any third party will rely on the information at its own risk. Veritau will not owe a duty of care or assume any responsibility towards anyone other than the client in relation to the information supplied. Equally, no third party may assert any rights or bring any claims against Veritau in connection with the information. Where information is provided to a named third party, the third party will keep the information confidential. 1 INTRODUCTION

1.1 The council has responsibilities for the health and safety of its employees, customers accessing services and people in the city. To meet these responsibilities, the council undertakes a broad and diverse range of activities.

1.2 Following a request by the Audit & Governance Committee, it was agreed that the main part of this year’s Health & Safety audit would focus on the council’s arrangements for ensuring safety at public events. This has been reported separately to management.

1.3 The 2015/16 audit reviewed progress against actions raised in the 2013/14 and 2014/15 Health & Safety audits. It was found that there were a total of 11 outstanding actions for which the target implementation dates needed to be revised or the action reviewed. These actions have therefore been followed up as part of this year’s audit. Due to the extent of the work involved in following up these actions, it was considered to be appropriate to report the findings separately to the main part of the audit.

Scope and Objectives

1.4 The first objective of this audit was to establish the progress made towards achieving the actions identified as part of the 2015/16 Health & Safety audit.

1.5 The second objective was to agree further actions or revised target dates where necessary to address any outstanding issues.

Key findings

1.6 At the time of the audit the Health & Safety team (H&S team) were in the process of combining with the H&S Team of North Yorkshire County Council (NYCC) to form a Shared Health and Safety Service. The intention is to align and where practicable to merge H&S systems, but work on this was at an early stage.

1.7 Many of the risks identified during the previous audits have now been mitigated and the H&S Team are undertaking work that will address the remaining actions. It was found that sufficient progress has been made to achieving six of the actions.

1.8 In five cases, work is ongoing to address the risks previously identified. In some cases, the H&S Team have changed their approach to the risks, resulting in the need for new actions. Issues regarding identifying significant corporate and non-domestic property risks (action 4 in the 2015/16 audit report) and Site Asbestos Liaison Officers (SALOs) and Site Legionella Representatives (SLRs) (action 9) are now being addressed differently. Officers said that properties are now being assigned a health and safety risk rating (action 6), but clear evidence to support this was not available as the premises register (see 2.9-10 below) was not complete. A gap analysis has been undertaken by the H&S Team for all corporate and non-domestic premises to identify where asbestos surveys are required. The review identified 11 premises that require surveys. These have been commissioned for 3 premises and requests for authorisation to carry out surveys have been issued for the other 8 (action 8). Health surveillance (action 11) now comes under the remit of Human Resources, who have raised additional concerns in relation to this.

1.9 Detailed discussion of the findings is set out below. Four new actions are set out in Appendix 1. The issue of overall risk ratings for properties has been combined with the premises register as a single action, which should address both issues. 2 FINDINGS

Area Reviewed – Lone Working (Actions 1 & 2)

2.1 The 2015/16 audit found that risks were not fully documented for services with an element of lone working. The H&S team were to assess the appropriateness of documentation in high-risk services and raise awareness of the need to complete lone working risk assessments.

2.2 Discussions with the H&S team found that lone working forms are just one part of audits of service areas. Lone-working risks are assessed by services using the lone-working compliance note (updated April 2017). The risk assessments are sent to the H&S team for review. A new checklist to help managers assess the risk of lone working, violence and aggression in their service areas has also been developed.

2.3 The H&S team reviewed the use of Skyguard warning devices and the Staff Warning Register (SWR). It was found that many Skyguard profiles, which contain key contact information for use should the device be activated, were incomplete. In addition the SWR had been used infrequently: out of 300 people with access, only 25 had used it.

2.4 A report was taken to the Joint Health and Safety Committee (JHSC) in June 2017 that recommended a review of lone working, violence and aggression risks across the directorates. In addition a report and presentation on the situation as regards lone working was provided to Corporate Leadership Group. Work is currently ongoing to review Skyguard usage and profile information and update risk assessments as appropriate. Once this has been completed, the H&S team will conduct ‘dip-sampling’ of Skyguard profiles on a rolling basis.

2.5 The work done by the H&S team addresses the issues identified in the previous audit. The actions outlined in the previous audit can be considered complete. The H&S Team also said the SWR will be monitored regularly, but this had not begun at the time of the audit.

Area Reviewed – Premises Registers (Actions 3 - 5)

2.6 The lack of a single, comprehensive premises register for corporate and non-domestic premises identifying the significant health and safety obligations the council has in relation to these premises had been identified as an issue in both the 2014/15 and 2015/16 audits. Documentation of obligations and risks was being stored in multiple file areas. Several services were involved, but they did not have a coordinated approach. The H&S Team also mentioned difficulties in retrieving property information from Techforge and limitations in Documentum.

2.7 It was found that the Health & Safety Risk Manager now regularly attends meetings with colleagues from Property Services, Housing, and Commercial Services. The meetings provide a discussion forum for the different services, allowing them to keep abreast of health and safety issues at council premises.

2.8 The H&S team are now also receiving updates from Commercial Services as and when properties are acquired or disposed of, leased or a lease is terminated, allowing them to update their records.

2.9 A register of the significant health and safety risks of corporate and non-domestic premises register is currently being developed by the H&S team and a similar register is being developed at NYCC. It will show health and safety responsibilities for services, corporate properties, local authority schools, and commercial properties. It will include a health and safety risk rating in order to inform the health and safety visit programme. Furthermore, it will identify the last advisor visit, the date of the most recent audit visit and due date for the next visit, as well as responsibilities for fire, asbestos, and Legionella, amongst other things.

2.10 At the time of the audit, the H&S team were working to resolve some functionality issues within the register between the NYCC and CYC versions and consequently had yet to populate it with all the relevant data, although efforts had begun in this area (for example, the dates of asbestos surveys at properties had been compiled). Completing the register will enable the H&S team to identify gaps in their records and provide management with a monitoring tool.

2.11 Actions 3 and 5, relating to coordination of services and updates on assets, can be considered complete. Although progress is being made towards completing Action 4 on the premises register, further follow up is required to confirm that issues have been resolved and the register updated with all required information.

**Area Reviewed – Fire Risk Assessments (Actions 6 & 7)**

2.12 The 2015/16 audit identified that not all properties had a health and safety risk rating and there was not a formalised follow up and escalation procedure for actions arising from fire risk assessments.

2.13 Discussions with officers found that properties are now assigned an overall risk rating of ‘high’, ‘medium’ or ‘low’. This is a judgement reached by the responsible health & safety officer based on fire, asbestos, Legionella and other health and safety risks at the property in question. The frequency of fire safety reviews has also been prioritised based on risk. However, due to the issues outlined in 2.10 above sufficient evidence was not available for all properties.

2.14 A formal follow up process is now in place. Once a health and safety audit has been completed, the service or property manager has 30 days to complete and return an action plan addressing the issues raised. If an action plan is not returned, then it is escalated to the relevant head of service and assistant director. This is clearly stated in the health and safety policy. 2.15 Action 6 (risk ratings) cannot be considered complete at this stage, but it is expected that the new premises register will address this issue. Therefore, a separate action has not been raised, but it is included in Action 1 in Appendix 1. As a formal follow up process is now in place, action 7 can be considered complete.

**Area Reviewed – Asbestos Risk Registers (Action 8)**

2.16 It was agreed during the last audit that a review of non-domestic council properties would be undertaken to identify those that did not have an asbestos survey or management plan in place.

2.17 As part of the compilation of the new premises health and safety risk register (see 2.9-10 above), a gap analysis has been undertaken as outlined in 1.8 above to identify where asbestos surveys are required. Furthermore, a new asbestos management register is being developed, which will replace the current format and properties with asbestos will receive an annual visit.

2.18 Progress has been made against this action as the service has now identified where asbestos surveys are required. Once surveys have been conducted for properties without them, then this action can be considered complete. An action has been raised regarding the completion of surveys.

**Area Reviewed – Asbestos & Legionella Site Representatives (Action 9)**

2.19 The 2015/16 audit found that there were no up to date lists of SALOs and SLRs for council premises and review forms often had the ‘responsible officer’ field left blank.

2.20 Discussion with the H&S team found that SALOs and SLRs are to be renamed ‘nominated persons’ in line with North Yorkshire County Council practice. The H&S Team said that responsibility for Legionella and asbestos should sit with a particular level of management (e.g. heads of service or head teachers at schools) as this better reflects the health and safety policy. Therefore, maintaining a list of names is not necessary as the relevant officer or head teacher retains overall responsibility.

2.21 The H&S team are updating the compliance notes for Legionella and asbestos to reflect this position. Consultation has currently commenced with trade unions and affected services. Training will then be provided to nominated persons, either face-to-face (for asbestos) or via e-learning (for Legionella), over the coming months. Ongoing training needs will be identified as part of the regular audit schedule. In order to facilitate this and other safety critical training, the Workforce Development Unit (WDU) are implementing a Learning Management (LMS) System which will assist in the roll out of training programmes, particularly e-learning.

2.22 It is critical that nominated persons understand their role and responsibilities. Although the H&S team have developed a plan to address the issue, it is yet to be fully implemented. The action is therefore outstanding and requires further follow up.

**Area Reviewed – Hand-Arm Vibration Syndrome Monitoring (Action 10)**

2.23 The 2014/15 and 2015/16 audits found that HAVS monitoring was inadequate because the paper forms in use were often incomplete, inaccurate, missing or delayed. It was agreed that a decision would be taken on implementing a new monitoring system.

2.24 Discussions with the Planning and Compliance Officer found that a new electronic vibration monitoring system has now been purchased to replace the old paper forms. The new system uses watches worn by users that record vibration levels over a period of time. At the time of the audit, the officer was training users and completing an inventory of machinery requiring monitoring prior to rolling out the system.

2.25 The Planning and Compliance Officer explained that the system includes an online portal to which data from the watches is uploaded automatically when they are placed in their docking station. He will receive automatic email alerts if an employee has breached safe usage levels and can also produce reports showing usage by individual employees. This information will be provided to managers for further investigation as required.

2.26 The paper-based monitoring system has now been replaced and the new system is more robust. The action can therefore be considered complete.

**Area Reviewed – Health Surveillance (Action 11)**

2.27 The 2015/16 audit found that the process for keeping the list of employees who require health surveillance up to date was not working. It was agreed then that managers would be required to provide an annual update of employees requiring health surveillance to Business Support.

2.28 Discussion with the H&S team, the Business Support Operations Manager (BSOM) and the Human Resources Wellbeing & Occupational Health Advisor (WOHA) found that a different approach is being taken to resolve the problem, but also that there is a related issue of non-attendance that is particularly prevalent in certain services.

2.29 The BSOM explained that new starters requiring surveillance are now identified through Work Health Assessment Forms (WHAFs) issued by the Recruitment team and added to the health surveillance list. However, Business Support only find out that staff members have left the council or are on long-term sick leave when they try to book appointments and managers decline them, which means staff may not be receiving a final health check.

2.30 The WOHA explained that the ‘gold standard’ is for employees to have a final health check before they leave as this helps protect the council against future liability claims. One means of identifying leavers would be to include a requirement on the leavers’ checklist for managers to inform Business Support that an employee is leaving who required health surveillance. It should be noted that it may be difficult to enforce such a health check of someone leaving the council, but refusal or non-attendance could be recorded on the appropriate record.

2.31 Non-attendance at appointments was highlighted during the audit as a particular issue. At 1/8/2017, there were 276 individuals who required health surveillance. Of these, 79 were overdue appointments, 18 of whom did not have appointments arranged. Of the 79 overdue individuals, 39 were from Waste Services. As of 31/10/2017 the situation had improved, but there were still 22 individuals from Waste Services who were overdue appointments.

2.32 The council is charged for non-attendance at appointments or if the appointment is cancelled within 48 hours of the arranged date. There is a clear financial risk to the council from non-attendance at appointments, as well as the inefficient use of Business Support time in reorganising these appointments. The WOHA suggested re-charging costs to services may incentivise managers to encourage attendance at appointments. This option should be explored as part of the review of occupational health arrangements that is being undertaken.

2.33 The original action requiring an annual update from managers is no longer appropriate and should be superseded with a requirement for managers to notify Business Support of leavers and staff members on long-term sick leave. The option for re-charging costs of non-attendance and the additional time taken by Business Support related to this to services should be explored. An action has been raised regarding these issues. 3 CONCLUSIONS

3.1 Overall, improvements have been made in the systems for managing the Health and Safety risks previously identified. Review of the actions raised in the 2015/16 audit found that six of the actions raised at that time (actions 1-3, 5, 7, and 10) have been completed or sufficient progress has been made in addressing the issues.

3.2 There are five actions that will need to be superseded with new actions and further follow up work carried out. Firstly, it will need to be confirmed that the new premises health and safety risk register (original action 4, see 2.9-10) has been completed and the outstanding technical issues resolved. Ensuring that it is finalised is important because it will be a key oversight and monitoring tool for a variety of health and safety risks. It will also provide evidence that properties have been assigned overall health and safety risk ratings as required by action 6.

3.3 Secondly, asbestos surveys (original action 8) need to be conducted for premises that do not have them. The H&S team have carried out work to identify these gaps in their records. Once surveys have been conducted, then action 8 from the 2015/16 report can be considered complete.

3.4 The H&S team are no longer maintaining a list of SALOs & SLRs as envisioned in action 9 of the 2015/16 audit. Instead, they are taking a new approach as outlined in section 2.19-22. Therefore, the original action is no longer appropriate and a new action has been raised to assess progress.

3.5 Finally, the action relating to health surveillance (original action 11) is no longer appropriate. As discussed in 2.27-2.33, a different approach is needed to address the issues, and so a new action has been raised.

## APPENDIX 1 – ACTIONS AGREED TO ADDRESS CONTROL WEAKNESSES

| Action Number | Report Reference | Issue | Risk | Agreed Action | Priority | Responsible Officer | Timescale | |---------------|------------------|----------------------------------------------------------------------|----------------------------------------------------------------------|--------------------------------------------------------------------------------|----------|---------------------|------------------------| | 1 | 2.6, 2.9-10 | The premises register is incomplete. | Health and safety responsibilities are not met in a timely manner. | The premises register will be completed and technical issues resolved. This will include entering the overall property risk ratings. | 2 | Head of Health & Safety | April 2018 | | 2 | 2.16-2.18 | Not all premises have asbestos surveys. | Asbestos risks are not appropriately managed. | The H&S team will conduct surveys for those properties that require them and include the results in Techforge. | 3 | Head of Health & Safety | April 2018 | | 3 | 2.19-2.22 | Legionella and asbestos compliance notes require updating and training needs to be provided to nominated persons. | Asbestos and Legionella risks may not be managed appropriately, increasing the likelihood of exposure to asbestos or Legionella. | a) The compliance notes for Legionella and asbestos will be updated.\
b) The appropriate level of training at council premises and schools will be identified.\
c) Training will be rolled out to officers who require it following the revision of the compliance notes. | 2 | Head of Health & Safety | A & B – April 2018\
C – April 2019 with interim update October 2018 | | | | | | | | | |---|---|---|---|---|---|---| | 4 | 2.27-2.33 | Staff members requiring health surveillance are not attending appointments. | Non-attendance has a potential cost to the council, both financially and in staff time. There is also a risk of future liability claims if staff members do not receive final health checks. | a) The leavers' checklist will be updated to include a requirement to notify Business Support if appropriate that the leaver requires a final health check.\
b) A decision will be taken on re-charging costs of non-attendance to services. | 3 | Head of Human Resources | July 2018 |

**Priorities for Actions**

| Priority | Description | |----------|-------------| | Priority 1 | A fundamental system weakness, which presents unacceptable risk to the system objectives and requires urgent attention by management. | | Priority 2 | A significant system weakness, whose impact or frequency presents risks to the system objectives, which needs to be addressed by management. | | Priority 3 | The system objectives are not exposed to significant risk, but the issue merits attention by management. |